Employment Application Form
Meridian Rehab Services Corp. is an Equal Opportunity Employer, dedicated to a policy of nondiscrimination in employment on any basis including age, sex, color, race, creed, national origin, religion, marital status, sexual orientation, political belief or disability.
Items with a "*" are required fields.
Personal Information
*First Name: *Last Name: Middle Name:
*Social Security No.:        
*Street Address: *City: *State:
*Zip Code:        
Telephone No.          
*Home:        
Work:        
Pager:        
*Email:        
Previous addresses if less than 2 years at present address.
Street Address: City: State:
Zip Code: Country:    
Emergency Contact:
Name:
Address:
Phone No.:
 
*If hired, can you furnish proof of age? Yes No
*If hired, can you furnish proof that you are legally entitled to work in the U.S.? Yes No
Have you ever been in the military? Yes No
If yes, list military branch:
Separation Date:    
Separation Rank:    
Are You in Natl. Guard/Reserve? Yes No
Are you bondable? Yes No
Have you ever been bonded? Yes No
 
*Within the past seven years, have you been convicted of a crime involving dishonesty or violence? (A conviction record will not necessarily be a bar to employment.) Yes No
If Yes, explain:
In order to assure proper placement of all associates; please list any special skills, training, or experiences, which qualify you for the position for which you are applying.
 
Availability
For what position are you applying?
Could you travel if required to by this position? Yes % of time No
Could you work overtime? Yes No
Date you are available to start work
I am seeking (Check one):
Per Diem Contracted Part Time Part time working to Temporary
Complete the hours available for work below.
  Sun Mon Tues Wed Thurs Fri Sat
From AM
To AM
From PM
To PM
Are you available to work: Weekends Holidays Rotating Shifts
 
Education
Names and Locations of Schools Attended Graduate? Courses of Study
Yes No
High School
College
Other (Name and type)
 
Work Experience
List below your four most recent employers, starting with your present or last employer. List under company name any periods of unemployment. If you were employed under another name, please enter under the company name.
Company Name Address & Phone Mo./Yr. Pay Rate Title of Job Held
Name of Supervisor 		Reason for Leaving
From To Starting Final
May we contact your present employer? Yes No
During the last 10 years, were you fired from any job for any reason, did you quit after being told that you would be fired, or did you leave by mutual agreement because of specific problems?
 
License/Certificate
Type of License/Certificate License Number License Expiration State of Issue
Drivers Class:
Professional:
CPR Card Type
 
References Personal/Professional
Name Title Company Phone Relationship
 
PLEASE READ THE FOLLOWING PARAGRAPH BEFORE SIGNING THIS APPLICATION
I certify that the information contained in this application is correct to the best of my knowledge and understand that any, misstatement or omission of information is grounds for dismissal in accordance with Infinia Health Cares policy. I authorize the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. In consideration of my employment, I agree to conform to the rules and regulations of Infinia Health Care and my employment and compensation can be terminated with or without cause, and with or without notice, at any time, at the option of either the company or myself. I understand that no unit manager or representative of Infinia Health Care other than an Officer of the Company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. In some states, the law requires that Infinia Health Care have my written permission before obtaining consumer reports on me, and I hereby authorize Infinia Health Care to obtain such reports.
*Applicant’s Signature *Date
  (Typing your name in the box above is a Digital Signature)    

 

Home   |   About Meridian   |   Services   |   Employment   |   Contact Us   |   News

©2007 Meridian Rehab Services